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Per-enrollee Medicare spending in West Virginia is about 5% lower than the national average.

Medicare enrollment in West Virginia

As of November 2019, there were 439,809 Medicare beneficiaries in West Virginia. That’s more than 24 percent of the state’s population, compared with less than 19 percent of the United States population enrolled in Medicare.

But 21 percent of West Virginia’s Medicare beneficiaries were eligible due to a disability as of 2017 (as opposed to being age 65+), versus 16 percent nationwide. According to data compiled by the University of New Hampshire, West Virginia had the highest percentage of disabled residents in the country in 2016 (although Alabama, Arkansas, Kentucky, and Mississippi all had a higher percentage of their Medicare beneficiaries eligible due to disability).

West Virginia also has among the nations highest percentages of elderly residents (age 65+). Combined with the high rate of disability, it makes sense that a larger-than-average number of West Virginia residents are enrolled in Medicare.

Medicare Advantage in West Virginia

26 percent of Medicare beneficiaries in West Virginia were enrolled in private Medicare Advantage plans in 2018. Nationwide, the average was 34 percent, so Medicare Advantage is a little less popular in West Virginia than it is nationwide. The other three-quarters of the West Virginia’s Medicare beneficiaries had opted for coverage under Original Medicare.

There is a robust Medicare Advantage market in West Virginia, although plan availability varies by county. The number of available plans in 2020 ranges from 17 to 26, depending on the county.

Medicare beneficiaries can switch from Medicare Advantage to Original Medicare or vice versa during the annual election period in the fall (October 15 through December 7), with coverage effective January 1. And as of 2019, there’s a Medicare Advantage open enrollment period in the first quarter of the year (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.

Medigap in West Virginia

Because Original Medicare includes out-of-pocket costs that can be substantial and that aren’t limited under the terms of Medicare’s coverage, many enrollees rely on Medigap plans to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that they would otherwise have to pay themselves.

According to data compiled by AHIP, there were 92,676 West Virginia Medicare beneficiaries with Medigap coverage as of 2016.

West Virginia implemented new regulations in 2019, requiring Medigap insurers that use attained-age rating (ie, prices that increase as enrollees get older) to adjust rates annually, as opposed to keeping them flat for several years and then adjusting them all at once when the insured crossed into a new age band. But the state amended the rules to allow insurers that were already using multi-year age bands to transition to the new method over a period of no more than five years. The state also clarified that insurers can continue to have a maximum rate that applies once an insured reaches a certain age (ie, rates do not have to continue to increase annually for an insured’s entire lifetime).

Medigap plans are standardized under federal rules, with ten different plan designs (denoted by letters, A through N). And federal rules allow for a six-month guaranteed-issue window for Medigap plans, which begins when the person is at least 65 and enrolled in Medicare Part B.

But federal rules do not guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability. The majority of the states have adopted rules to ensure at least some access to Medigap plans for under-65 enrollees, but West Virginia is not among them.

According to the West Virginia Office of the Insurance Commissioner, there is no state rule requiring Medigap insurer to offer coverage to people under 65, and most of the insurers choose not to (people under 65 who are eligible for Medicare are, by definition, disabled, so their medical expenses can be expected to be higher than the average enrollee who qualifies for Medicare based on age alone). But the Office of the Insurance Commissioner noted that there are two Medigap insurers in West Virginia that do offer plans to people under the age of 65:

United American offers Plan A

Highmark Blue Cross Blue Shield offers all of their Medigap plans to enrollees under age 65, but only if the person is transitioning from another Highmark plan to Medicare.

The premiums for Medigap plans for people under 65 are higher than the standard premiums for people who are eligible for Medicare due to their age. Disabled enrollees who have a higher-priced Medigap plan when they’re under 65 are allowed another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point.

Medicare Part D in West Virginia

Original Medicare does not cover outpatient prescription drugs. People enrolled in Medicare plans can obtain prescription coverage through a Medicare Advantage plan (most Advantage plans have built-in prescription coverage), an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D prescription drug plan.

188,977 West Virginia Medicare beneficiaries had stand-alone Part D coverage as of November 2019, and another 121,904 had Part D coverage integrated with Medicare Advantage plans.

Medicare spending in West Virginia

In 2016, Original Medicare spent an average of $9,070 per beneficiary in West Virginia, based on data standardized to account for regional differences in payment rates. The data did not include costs for Medicare Advantage enrollees, but three-quarters of West Virginia Medicare beneficiaries had Original Medicare.

Nationwide, average per beneficiary Original Medicare spending that year was $9,533 per enrollee, so Medicare spending in West Virginia was about 5 percent lower than average. In three states (Florida, Louisiana, and Texas), Original Medicare’s per-beneficiary spending was more than $11,000, while in Hawaii it was just $6,441.